Enhanced Recovery after Surgery in Breast Reconstruction: A Systematic Review

Abstract

Background Enhanced Recovery after Surgery (ERAS) principles have received focused attention in breast reconstruction. Many protocols have been described in the literature for both autologous and alloplastic reconstruction. This systematic review serves to better characterize successful ERAS protocols described in the literature for potential ease of adoption at institutions desiring implementation. Methods A systematic review of ERAS protocols for autologous and alloplastic breast reconstruction was conducted using Medline, the Cochrane Database, and Web of Science. Results Eleven cohort studies evaluating ERAS protocols for autologous (n = 8) and alloplastic (n = 3) breast reconstruction were included for review. The majority compared with a retrospective cohort of traditional perioperative care. All studies described the full spectrum of implemented ERAS protocols including preoperative, intraoperative, and postoperative phases of care. Most frequently reported significant outcomes were reduced length of stay and opioid use with ERAS implementation. No significant change in major complication or readmission rate was demonstrated. Conclusion Based on this systematic review, several core elements that make up a successful perioperative enhanced recovery protocol for breast reconstruction have been identified. Elements include patient counseling and education, limited preoperative fasting, appropriate thromboprophylaxis and antibiotic prophylaxis dependent on reconstructive method, preoperative antiemetics, multimodal analgesia and use of local anesthetic, goal-directed intravenous fluid management, prompt removal of drains and catheters, early diet advancement, and encouragement of ambulation postoperatively. Implementation of ERAS protocols in both autologous and alloplastic breast reconstruction can positively enhance patient experience and improve outcomes by reducing length of stay and opioid use, without compromising successful reconstructive outcomes.

Setting up a new microsurgical breast service in a non-tertiary hospital: Is it safe, and do outcomes compare to centres of excellence?

“…In the United Kingdom, autologous breast reconstruction has an average length of stay of 5 days 24,25 . The recent utilisation of enhanced recovery protocols (ERAS) by high-volume centres have revolutionised how microsurgical breast reconstruction is managed in the perioperative period 7 . A key aim of enhanced recovery protocols (ERAS) is reducing the length of hospital stay.…”

“…A key aim of enhanced recovery protocols (ERAS) is reducing the length of hospital stay. Recent publications of enhanced recovery protocols from well-established large volume centres have demonstrated a median length of stay between 4-7 days [4][5][6][7][8][9][10][11]26 .…”

“…Many units see autologous reconstruction as a complex procedure that is best performed at a high volume centres with a long-established history of microsurgery and excellent outcomes [4][5][6][7][8][9][10][11][12] . The problem with this approach is that patients can be denied this form of reconstruction due to a geographical availability, especially when the surgery is time critical, or be required to travel significant distances, often with complete transfer of their care, to a centre that offers it 13 .…”

Optimizing Postoperative Pain Control in Autologous Breast Reconstruction: A Systematic Review

“…As mentioned previously, multimodal analgesic protocols are likely to become more commonly implemented in breast reconstruction recovery protocols, particularly with the increased utilization of ERAS protocols in hospital systems. 49 Based on a recent systematic review on ERAS implementation in breast reconstruction, 49 across 11 different studies analyzed demonstrated enhanced patient experience and improved outcomes by reducing LOS and opioid use, without compromising successful reconstructive outcomes. The most effective elements to enhance patient recovery following autologous or alloplastic breast reconstruction included: patient counseling and education, limited preoperative fasting, appropriate thromboprophylaxis and antibiotic prophylaxis, preoperative antiemetics, multimodal analgesia and use of local anesthetic, goal-directed intravenous fluid management, prompt removal of drains and catheters, early diet advancement, and encouragement of early ambulation.…”

Postoperative Free Flap Breast Protocol Optimizing Resources and Patient Safety

“…Previous studies have analyzed the efficacy of various enhanced recovery after surgery (ERAS) protocols in microsurgical, DIEP, and alloplastic breast reconstruction cases. [28][29][30] This study aims to evaluate outcomes with this particular DIEP pathway to assess its safety and feasibility in clinical practice at a major academic medical center.…”